Action Points

Note that the guidelines still allow physicians to use their best clinical judgment in prescribing treatment for an individual patient.

ATLANTA, July 24 -- Early, aggressive treatment of rheumatoid arthritis with biologic agents and potent drug combinations has moved front and center in the newly updated American College of Rheumatology practice guidelines.

Patients with high disease activity and poor-prognosis features warrant consideration for first-line treatment with a biologic response modifier or a combination of nonbiologic disease-modifying antirheumatic drugs (DMARDs), according to the guidelines published in the June 15 issue of Arthritis & Rheumatism.

Even patients with low disease activity at diagnosis might be candidates for biologic DMARDs and combination therapy if they have high-risk or poor-prognosis features.

The guidelines reflect recognition that early aggressive intervention offers patients the best opportunity to minimize or avoid joint damage and disability, Kenneth G. Saag, M.D., of the University of Alabama at Birmingham, who was lead author of the guidelines. However, the guidelines leave ample room for clinical judgment in treating an individual patient.

"The recommendations developed are not intended to be used in a cookbook or prescriptive manner, or to limit a physician's clinical judgment," said Dr. Saag. "They provide guidance based on clinical evidence and expert-panel input."

The update, the first by the ACR since 2002, gave formal recognition and a systematic approach to treatment strategies that have been employed widely for several years: early use of nonbiologic DMARDs and biologic agents.

For example, the panel recommended triple-DMARD therapy "for all patients with poor prognostic features and moderate or high levels of disease activity, regardless of disease duration." The authors noted that the majority of patients with a confirmed diagnosis of rheumatoid arthritis (RA) already are treated with nonbiologic DMARDs or biologics.

The authors addressed only the use of traditional DMARDs and biologics. Steroids, anti-inflammatories, and other therapies used in RA were beyond the scope of the guidelines.

The 2008 guideline also is the first from the ACR to be developed by a formal group process. Prior iterations had evolved primarily from informal consensus, the authors said.

The guidelines panel recommended leflunomide (Arava) or methotrexate monotherapy as initial treatment for virtually all patients, regardless of disease duration, disease activity, or poor-prognosis features. However, clinical flow charts that accompany the recommendations waste little time in arriving at aggressive therapy, particularly in patients with unfavorable clinical characteristics.

Other key recommendations in the guideline include:

Use of tumor necrosis factor inhibitors in patients with new or early RA and severe, worsening symptoms.

Delay the start or resumption of treatment with methotrexate, leflunamide, or a biologic agent in patients who have active bacterial infections, herpes zoster infection, hepatitis B or C, or active or latent or suspected tuberculosis.

Prohibition on anti-TNF agents in patients who have a history of heart failure, lymphoma, or multiple sclerosis.

Dr. Saag and many of the co-authors acknowledged multiple relationships with medical and healthcare industries.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco

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